Form DH4115 "Application for Septic Tank Contracting Course Approval" - Florida

What Is Form DH4115?

This is a legal form that was released by the Florida Department of Health - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2003;
  • The latest edition provided by the Florida Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DH4115 by clicking the link below or browse more documents and templates provided by the Florida Department of Health.

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Download Form DH4115 "Application for Septic Tank Contracting Course Approval" - Florida

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STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTING
COURSE APPROVAL
COURSE APPLICATION FEE OF $25.00 PER CLASSROOM HOUR NOT TO EXCEED $150.00. FORWARD COMPLETED
APPLICATION POSTMARKED NO LATER THAN 60 DAYS PRIOR TO THE EARLIEST DATE OF THE COURSE TO:
DEPARTMENT OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
SECTION I
PROVIDER NAME
PROVIDER NUMBER
COURSE TITLE
COURSE LEVEL
[ ] REGISTERED or [ ] MASTER LEVEL
SECTION II
COURSE LOCATION
COURSE DATE
LIST COURSE INSTRUCTORS AND ATTACH QUALIFICATIONS
COURSE SECTION TITLE
PLEASE INDICATE THE COURSE HOURS YOU INTEND TO PROVIDE AND ATTACH THE COURSE SYLLABUS
OSTD SYSTEM INSTALLATIONS
OSTDS & PUBLIC HEALTH
HYDRIC SOIL INDICATORS
OSTD SYSTEM REPAIRS
ENVIRONMENTAL EFFECTS
MINERAL AGGREGATE COURSE
OSTD SYSTEM DESIGN/DOSING
AEROBIC TREATMENT UNITS
SAFETY
ALTERNATIVE OSTD SYSTEMS
PORTABLE RESTROOM CONTRACTING
* BUSINESS PRACTICE
INNOVATIVE OSTD SYSTEMS
SEPTAGE TREATMENT & DISPOSAL
* OFFICE MANAGEMENT
OSTD SYSTEM MAINTENANCE
BASIC SOILS COURSE
OTHER:
TOTAL COURSE HOURS
AT $25.00 PER HOUR = $
*May only constitute up to 1/3 of total course hours.
SECTION III
I AFFIRM THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT.
Print or Type Name of Authorized Representative
Signature of Authorized Representative
Date
FOR
Postmark Date
Check Number
Approval Date
HSES
Check Date
Expiration Date
OFFICE
Check Amount
Reviewed by
USE
Denial Date
ONLY
Course Number
DH 4115, 07/03 Incorporated: Policy on Requirements for Continuing Education Courses and Course Providers
STATE OF FLORIDA
DEPARTMENT OF HEALTH
APPLICATION FOR SEPTIC TANK CONTRACTING
COURSE APPROVAL
COURSE APPLICATION FEE OF $25.00 PER CLASSROOM HOUR NOT TO EXCEED $150.00. FORWARD COMPLETED
APPLICATION POSTMARKED NO LATER THAN 60 DAYS PRIOR TO THE EARLIEST DATE OF THE COURSE TO:
DEPARTMENT OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
SECTION I
PROVIDER NAME
PROVIDER NUMBER
COURSE TITLE
COURSE LEVEL
[ ] REGISTERED or [ ] MASTER LEVEL
SECTION II
COURSE LOCATION
COURSE DATE
LIST COURSE INSTRUCTORS AND ATTACH QUALIFICATIONS
COURSE SECTION TITLE
PLEASE INDICATE THE COURSE HOURS YOU INTEND TO PROVIDE AND ATTACH THE COURSE SYLLABUS
OSTD SYSTEM INSTALLATIONS
OSTDS & PUBLIC HEALTH
HYDRIC SOIL INDICATORS
OSTD SYSTEM REPAIRS
ENVIRONMENTAL EFFECTS
MINERAL AGGREGATE COURSE
OSTD SYSTEM DESIGN/DOSING
AEROBIC TREATMENT UNITS
SAFETY
ALTERNATIVE OSTD SYSTEMS
PORTABLE RESTROOM CONTRACTING
* BUSINESS PRACTICE
INNOVATIVE OSTD SYSTEMS
SEPTAGE TREATMENT & DISPOSAL
* OFFICE MANAGEMENT
OSTD SYSTEM MAINTENANCE
BASIC SOILS COURSE
OTHER:
TOTAL COURSE HOURS
AT $25.00 PER HOUR = $
*May only constitute up to 1/3 of total course hours.
SECTION III
I AFFIRM THAT ALL INFORMATION CONTAINED IN THIS APPLICATION IS TRUE AND CORRECT.
Print or Type Name of Authorized Representative
Signature of Authorized Representative
Date
FOR
Postmark Date
Check Number
Approval Date
HSES
Check Date
Expiration Date
OFFICE
Check Amount
Reviewed by
USE
Denial Date
ONLY
Course Number
DH 4115, 07/03 Incorporated: Policy on Requirements for Continuing Education Courses and Course Providers
INSTRUCTIONS:
SECTION I
Provider name:
Name of the organization or sponsor approved to provide septic tank
contracting continuing education courses.
Provider number: Approval number issued by the department to the course provider on
DH Form 4116, 07/03.
Course title:
Title of proposed course. Must be indicative of course content.
Course level:
Select intended course level.
SECTION II
Course location:
Provide specific addresses and dates for the locations where the approved
course will be provided.
Course instructors List the full name of all instructors and their corresponding course section
Section title:
titles. Instructors must meet one of the following qualifications: have a
minimum of three years of work experience in the subject matter to be
presented, or have a four year college degree or graduate degree and related
work experience, or be a master septic tank contractor, or be a state
certified plumber with at least three (3) years of experience in their technical
area of licensure, or be a registered septic tank contractor with at least three
(3) years of experience in their technical area of licensure, or be a state
certified environmental health professional with at least three (3) years of
work experience in their technical area of certification. Attach
documentation of qualifications for each instructor.
Course hours:
Indicate the type and amount of training to be given in the listed areas.
Course approval application fee is $25.00 per course hour, not to exceed
$150.00 per course approval.
SECTION III
The authorized representative of approved course provider acknowledges understanding of the
affirmation statement by printing, signing and dating the application.
Mail completed application to:
DEPARTMENT OF HEALTH
BUREAU OF ENVIRONMENTAL HEALTH, BIN #A08
4052 BALD CYPRESS WAY, TALLAHASSEE, FL 32399-1710
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